Types of Apps

From an interdisciplinary perspective, healthcare apps are designed for intersection of the practice of healthcare and information systems. The practice domain is highly variable and includes medicine, nursing, self-care, public health, and many other applications. Although this lesson is longer compared to others in this course, it is still only a cursory introduction to healthcare apps using a few examples. There is great diversity and specialization in this area. As a field of study or business sector, there is still much to be invented, improved, and moved into the market.

The American Health Information Management Association (AHIMA) defines an information system as “An automated system that uses computer hardware and software to record, manipulate, store, recover, and disseminate data (that is, a system that receives and processes input and provides output”. Information systems are all around you. This chapter is being presented to you from a Web Application , which is a type of information system that makes dynamic websites. You are likely reading it on a computer (e.g. laptop) or a mobile device (e.g. phone), both of which are also information systems.

The traditional abstract way to think of an information system, is a system of inputs, processes, and outputs. For example, a physician enters a medication prescription into the computer(an input), the computer checks the prescription for errors(process), and then the computer sends it to the pharmacy (outputs). By the way, the part of an electronic health record that accepts medication orders is call the computerized provider order entry system (CPOE). The “C” and the “P” in the name are obvious and unnecessary, but still typical usage.

Information systems are usually tailored to a task or setting and not well suited for other tasks. For example, a laptop personal computer is suited for light document and business app use, but may not have the (video) processing power to run immersive games. Similarly, some computers in industry are optimized for transactional use, and can store and fetch small sizes of data very very quickly. The same computer would not work well for analytical use, which requires large amounts of computations and processing.

Keep in mind that the “systems” described below may be their own app (or program ) and run independently of other systems, or they may be integrated components of a larger system. For example, many organization’s billing systems are separate from their electronic health record ( EHR) systems. However many organizations have their billing systems and EHR systems integrated in one application. Also, there are many many types of specialized boutique IT systems, so if you put any healthcare setting or process in front of the word “system”, it probably exists.

Electronic Health Record

Electronic Health Record (EHR) systems are a computer-enhanced replacement to paper medical records. EHR systems are the foundation for clinical care, revenue cycle, and quality improvement.

According to HIMSS, The EHR is “a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.

In 1991, a year before Al Gore created the internet , the Institute of Medicine defined EHRs, in a way that still works descriptively, albeit is not aspirational: “The set of components that form the mechanism by which patient records are created, used, stored, and retrieved. A patient record system is usually located within a health care provider setting. It includes people, data, rules and procedures, processing and storage devices (e.g., paper and pen, hardware and software), and communication and support facilities.

EHRs manage clinical records and data.

Simply, an EHR is a computer system that primarily supports the healthcare functions of healthcare organizations. However, they can be extremely complex in order to support large and complex organizations.

EHR Users

EHR users are as diverse as the healthcare industry’s workforce. Dozens of types of health care providers who use EHRs to document patient care and communicate to other providers and patients. General Counsel (lawyer) and compliance staff use the EHR to ensure adherence to laws, and to protect the legal risk to the organization. Medical coders and revenue staff use the EHR to generate the correct documentation needed for billing. Quality improvement, safety, and research staff use the data in the EHR to produce analytics and evidence. Patients and family care providers use the EHR to schedule visits, manage medications, and coordinate care. Public health, such as local and federal health departments EHRs to conduct disease surveillance and encourage desirable provider behaviors. The very different needs of this many disparate EHR users can create inefficiencies, compromises, and conflicts. For example, compliance officers may require the EHR to have additional patient information fields, that providers are required to complete, but does not directly support the provider’s ability to care for the patient.

What exactly is an EMR, then?

EHR vs EMR – For most of its history, computers that performed the function that paper patient records performed were called Electronic Medical Records. Between 2005-2010 the National Alliance for Health Information Technology (NAHIT) and several other Health IT organizations pushed for redefining and rebranding the EMR, and the Electronic Health Record was born. The quaint out-dated “EMR” was redefined as only a single organization’s medical record, and the new innovative “EHR” was defined as “built to share information with other health care providers, such as laboratories and specialists, so they contain information from all the clinicians involved in the patient’s care. “ The distinction was, and still is, considered “a world of difference” by many national HIT leaders and academics. The irony is EMR vendors simply scratched out the “M” and added a “H” to product names. 15 years later interoperability (sharing) continues to be abysmal in EHRs, and NAHIT is defunct.

The final nail in EMR’s (the word, not the thing) coffin was the government EHR Adoption Incentive programs and more specifically ONC’s Health IT Certification mandate in 2009. Through government policy we legally defined what EHR is (and is not). You can find the latest EHR Base Definition in the Federal Register. In the US, EHR is defined by having the capabilities to do the following:

  • Includes patient demographic and clinical health information, such as medical history and problem lists
  • Capacity to provide clinical decision support
  • Capacity to support physician order entry
  • Capacity to capture and query information relevant to health care quality
  • Capacity to exchange electronic health information with, and integrate such information from other sources

Computerized Provider Order Entry

Physicians orders are official directions regarding medications, procedures, treatments, therapy, diagnostic tests, laboratory tests, and nutrition. For example, a prescription is an order for medicine. Nurses, dentists and other providers also use orders formalize directions in their respective clinical areas. Traditionally, orders were placed using paper or verbally. Computerized Provider Order Entry (CPOE) no only replaces written and verbal orders, but transforms and improves the process with the help of a computational platform. Coupled with a clinical decision support system, CPOE has the capability of applying logic, evidence, and heuristics to assist the provider with making optimal ordering decisions.

CPOE is thought to be instrumental in achieving the following four goals:

  • Prevent, reduce, or eliminate medical errors and adverse drug events (ADEs) – CPOEs can ensure medication dosages are correct, allergies and contraindications are avoided, and help reduce the 98,000 patients who die each year in U.S. hospitals due to medical errors
  • Improve patient safety – Through CPOE decision logic and evidence that supports informed healthcare decisions and promoting high-value health care decisions.
  • Reduce unnecessary variation in health care – CPOE helps the provider make optimal ordering decisions and improve adherence to evidence-based practice. For example, a specific diagnosis may have a set of orders associated with it. The CPOE application uses pre-programmed to facilitate the care process and guide the provider to follow accepted protocols.
  • Improve efficiency of health care delivery – electronic orders are sent, received, and executed more quickly. CPOEs also encourage adherence to formularies and order sets that promote appropriate utilization

Clinical Decision Support

Computerized clinical decision support are applications (apps) that help providers make better decisions. The computer matches the patient’s information to a clinical knowledge base, and patient-specific assessments or recommendations are then communicated effectively at appropriate times during patient care For example, CDS within an EHR might suggest lists of possible diagnoses, drug-allergy alerts, duplicate testing reminders, drug interaction alerts, drug formulary guidelines, or preventive care reminders.

A CDS System built into the EHR must have a knowledge-base of rules and evidence, and a way to analyze the patient data against the knowledgebase. The final and crucial step is how the system communicates the ‘help’ to the provider. Popup alerts may be used to notify the provider, but these are considering distracting at best should be used sparingly. Non-invasive message techniques like flashing info-buttons, highlighting, or verbal queues are less annoying but perhaps easier to overlook. CDS should always facilitate an action when possible (such as “one-click to order alternative”) and provide detailed reference information that supports the clinical recommendation.

Patient Monitoring System

The 1980s just called, -and they want their patient monitor back

Patient monitoring systems monitor physiological data. They capture raw data, process it into a way we can understand it, and then communicate and display it. They also save the data for use later. In some cases, patient monitoring systems may interface directly to the EHR where it can be viewed by a physician in different location.

Patient monitoring systems are used in both inpatient and outpatient settings, including intensive care units, critical care units, operating suites, PACUs, ambulatory surgery centers, and many other sites.

Patient monitoring systems are used in both inpatient and outpatient settings, including intensive care units, critical care units, operating suites, PACUs, ambulatory surgery centers, and many other sites. Unlike EHRs, patient monitoring systems are classified as medical devices and are regulated by the FDA. However, the system that stores patient monitoring data after it is initially captured, -called a Medical Device Data System (MDDS), is NOT considered a medical device for regulation because it is not intended for active patient monitoring.

 

Billing/Revenue Cycle System

The healthcare revenue cycle is a complex and providers must perform multiple tasks to ensure they are reimbursed for their services. The systems supporting the revenue cycle include the EHR and Billing(often combined into the same system) and miscellaneous accounting systems (expenditure, control, forecasting, etc.).

  1. During scheduling and registration at a hospital or doctor’s office , patient information needed for billing is entered in the system. This includes (patient demographics) name, address, phone number, gender, sex, race, date of birth, ethnicity, preferred language, insurance information and guarantor information, co-payments, and deductibles.
  2. Any medical are that is delivered is documented in the patient’s EHR. Charges may be automatically generated by the system as a by-product of documentation, or charges for services may be manually entered in the system. Professional coders review the clinical documentation and any transcribed documents such as dictated notes, in order to assign the appropriate code for billing.
  3. When the insurance is billed, the provider transmits information to the payer: procedures, dates, diagnoses, and other information needed for billing.

 

 

Practice Management Systems

Practice management systems support the business of physician’s office or clinic. Practice management software provides a combination of financial and administrative functions. Many practice management systems are fully integrated with EHR software. Common practice management software functions are:

OpenEMR Practice Management – Scheduling Screen
  • Patient registration
  • Patient Scheduling
  • Staff Scheduling
  • Billing and receivables management
  • Reporting on clinical and business functions
  • Management of clinical data and interface and integration with EHRs.

 

 

Health Information Exchange

Health Information Exchange (HIE) involves the sharing of electronic health information across organizational boundaries. For example, if a patient is transferred from a hospital to a rehabilitation facility, an HIE would make it possible for that patient’s records to be electronically shared between the hospital’s EHR system and the rehab EHR system. Similarly, a primary care provider can access the records from a patient’s emergency department visit. A fully functional HIE would make it easy for the school clinic to access an an out-of-state college student’s records from home. Local and state health departments also use HIEs for more robust disease surveillance. In addition to sharing patient information, HIEs may also support secure provider-provider or patient-provider communication, abstracted data for research, clinical quality measures derived from patient records, and others. HIEs may be controlled by patients, centralized (e.g. there is a central exchange hub), or decentralized (peer to peer). HIE is an evolving area where technologies, standards, terminologies, and overall approaches have refreshed every 5 years or so. This rapid change contributes to terminology confusion, costs from constant changes, and the common perception (perhaps misconception) that the technology is not yet mature.

The HIE Struggle

The benefits of HIE have been examined for over a decade. The evidence of a HIE benefit is growing but is sparse. To patients and casual thinkers, HIE’s appear to be obviously and profoundly helpful: The doctor now has the ability to see ALL information. If they did an xray at the ED last night, they do not need to run another one at the PCPs office today. They can see medications and allergies on patients that do not have the ability to communicate these. However, it has been difficult for healthcare researchers to 1) measure benefits of HIEs, and 2) prove that the HIE contributed to the benefits. However, in theory, HIEs should be awesome

HIE Benefits

ONC considers HIE so instrumental to quality and cost reduction, that they not only require EHRs to have HIE capability, they also provide billions of $USD to research funding and direct funding to HIEs nationally. Despite murky evidence, the target benefits of HIE (sharing records across providers)include:

  • Avoid readmissions
  • Avoid medication errors
  • Improve diagnoses
  • Decrease duplicate testing
Crabs eat caduceus in Maryland. Perhaps coincidentally, every Chesapeake Bay blue crab that is caught in Maryland is born in the deeper waters of Virginia and crossed the state lines to contribute Maryland’s crabby identity. A D.C. politician said that when Virginia sends its crabs, “they’re not sending their best… They’re sending crabs that have lots of problems”.

 

 

The term Health Information Exchange (or HIE) may be used to describe an external app (and corresponding support organization) or a feature within an EHR.

HIE Organizations

Examples HIE organizations include state and regional HIEs, and national HIE systems. This illustrative list of HIEs implies that current HIEs in the US are generally state efforts. There are numerous State Health Information Exchanges originally started with federal grant money. Local geography HIEs (often called Regional Health Information Organizations ) aim to connect healthcare providers within a smaller geographic area, usually a metropolitan area. MedVirginia is notable HIE serving the Richmond, Virginia region with a notable history. MedVirginia is one of the the earliest sustainable HIEs, and the first HIE to connect with the Nationwide Health Information Network, the Social Security Administration’s Health IT. Another oldie but goodie is “Chesapeake Regional Information System for our Patients” or CRISP. Despite the regulatory challenges, CRISP crosses state lines and serves both Maryland and the District of Columbia.

HIEs are not simply local government and not-for-profits, and can also be national corporate organizations. SureScripts is a company that successfully brought most pharmacies and medical providers online. By 2014, SureScripts supported the bidirectional exchange of prescription and med refill information for 70% of providers and 96% of pharmacies in the US. SureScripts had medication interfaces with virtually every EHR and was uniquely positioned to expand exchange to all health information. However, HIE is a difficult business (more on that below) and by 2019 no HIE network vendor has significantly driven in the market.

SureScripts, CRISP, and MedVirginia are examples of external HIE organizations that provide the infrastructure for EHRs to share data and sometimes provide an external app for providers to look up patient data. By law, certified EHRs in the USA must have HIE capabilities. For the purpose of Meaningful Use (a US EHR incentive program) compliance and payments, “HIE capabilities” could initially be satisfied by securely emailing summary of care PDFs. However, structured searchable data will need to be exchanged for HIEs to reach their full potential.

Direct

Other Systems & Ancillary Systems

 

 

Ancillary Systems The term ancillary services is generally used to describe services not provided by physician, -each with specialty information systems designed to support them:

  • Laboratory tests that support accurate diagnosis of patients
  • Physical therapy, nutrition counseling, inventory and dispensing of medications.
  • Services such as home care aides, assisted living facilities, hospice services, etc. that assist patients in managing activities of daily living or improve their quality of life
Images of brain viewed in radiology system.

Imaging is the visual display of structural or functional patterns of organs or tissues for diagnostic evaluation. In addition to visualizing the parts of the body, biomedical imaging techniques are used to measure physiological and metabolic responses to physical and chemical stimuli. Common tests performed by medical imaging devices include:

  • Computed tomography (CT) scan is a diagnostic procedure that uses special x-ray equipment (the scanner) to obtain cross-sectional pictures of the body.
  • Positron emission tomography (PET) scan is a nuclear medicine imaging technique that produces a three-dimensional image of functional processes in the body.
  • Ultrasonography uses sound waves to produce an image. Echoes are received as input from a device called a sonographic probe and then are translated into pixels for creation of an image.
  • Magnetic resonance imaging (MRI) device works by surrounding the human body with a magnetic field and then flooding it with a radio frequency pulse that produces an image of the body’s interior structure.
  • Electrocardiography (ECG) machine provides an interpretation of the electrical activity of a heart over time, captured and externally recorded by skin electrodes.

Diagnostic imaging tests are normally managed by a Radiology Department that utilizes a Radiology Information System (RIS) to process orders for these diagnostic imaging tests. RIS supports scheduling, result reporting and imaging tracking and stores, organizes, and distributes patient radiological data, including a report of the interpretation by a radiologist. Radiologist reports are often interfaced to the EHR and are considered “results” that are displayed in an EHR.

 

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